The Medical Policies and Clinical Utilization Management (UM) Guidelines below were developed and/or revised to support clinical coding edits. Note, several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed. For markets with carved-out pharmacy services, the applicable listings below are informational only.


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  • Notes/updates:

Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive.

  • *DME.00037 — Added devices that combine cooling and vibration to the Investigational (INV) & not medically necessary (NMN) statement
  • *LAB.00027 — Added Mediator Release Test to INV&NMN statement
  • *LAB.00033 — Clarified INV&NMN statement to include 4Kscore and AR-V7
  • *OR-PR.00003:
    • Clarified medically necessary (MN) position statement criteria 2 to 4
    • Added statement that use of prosthetic devices that combine both a microprocessor controlled knee and foot-ankle prosthesis is considered INV&NMN for all indications
  • *SURG.00011:
    • Added new MN and INV&NMN statements addressing amniotic membrane‑derived products for conjunctival and corneal indications, including KeraSys and Prokera
    • Added new products to INV&NMN statement
  • *SURG.00045:
    • Added erectile dysfunction, Peyronie’s disease and wound repair to the INV&NMN statement
    • Revised title
  • *SURG.00121 — Added INV&NMN statement to address use of transcatheter tricuspid valve repair or replacement for all indications
  • The following AIM Specialty Health® updates were approved on June 6, 2019:
    • Advanced Imaging:
      • Imaging of the Heart
      • Oncologic Imaging
      • Vascular Imaging
    • Proton Beam Therapy
    • Rehabilitative Therapies — Physical Therapy, Occupational Therapy and Speech Therapy (New)


To view all the updates select the Medical Policies and Clinical Utilization Guidelines attachment.

Featured In:
October 2019 Anthem Blue Cross Provider News - California